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Hypo or ‘Dumping Syndrome’?

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Do You Know The Difference?

 

In the early days after surgery I worried about ‘dumping syndrome’ and read about it extensively. I knew the signs, how it would present itself, what to do and perhaps most importantly how to avoid it. For the main part that worked and I was able to pass on my information and tips in a ‘Dumping Syndrome’ feature (read it here).

 

Then I started to get queries about something that appeared to be like dumping but was, on closer examination, quite different – namely reactive hypoglycaemia. Like dumping it didn’t affect everyone post WLS but enough to send me back to the books to find out more. Here’s what I read, what can help you if you suffer and what to do if and when it does.

 

 REACTIVE HYPOGLYCAEMIA

Reactive hypoglycaemia post gastric bypass

 

What is it?

Reactive hypoglycaemia (non-insulinoma pancreatogenous hypoglycemia syndrome) is a seemingly rare and potentially serious complication following gastric bypass. Normal glucose levels are between 4.4 to 6.1 mmol/L (82 to 110 mg/dL). The brain can only use glucose to function. If the blood glucose level falls too low, the brain cannot function! Diabetics who inject themselves with too much insulin, can develop reactive hypoglycaemia because insulin drops their blood glucose to very low levels. Low blood glucose levels can occur in certain patients after gastric bypass (exact number not known) and this can produce several symptoms of varied severity.

 

Mild Hypoglycaemia (~ blood glucose down to 4.0 mmol/L [75 mg/dL])
  • Increased or sudden hunger
  • Feeling shaky, dizzy or nervous
  • Pounding heartbeat
  • Sweating (cold and clammy)
  • Numbness or tingling around the mouth
  • Headache or stomach ache
 
Moderate Hypoglycaemia (~ blood glucose 2.5 – 3.9 mmol/L [40-74 mg/dL])
  • Headache
  • Anxiety
  • Nausea
  • Confusion and/or difficulty concentrating
  • Slurred or slow speech
  • Impaired vision
 
Severe Hypoglycaemia (~ blood glucose 0 – 2.4 mmol/L [0-39 mg/dL])
  • Dizziness
  • Irritability
  • Drowsiness / Fatigue
  • Seizures and / or convulsions
  • Loss of consciousness

 

How do I find out if I have it?

If you think you may have low blood sugar after eating, you should measure your blood sugar level using a glucometer available at any pharmacy. Do the test an hour before a meal, a few minutes after eating, an hour afterward, two hours after, etc. Keep a food log and keep track of your blood glucose readings at all the various times before and after meals. Also track your symptoms and your glucose level during these symptoms.

If your blood glucose is less than 4 mmol/L (<82 mg/dL) at any one of these measurements, please call 514-747-8193 for a follow-up visit. Bring the results you recorded with you.

 

How is reactive hypoglycaemia treated?

You and the bariatric team need to understand what’s going on with your body. Your food log including the times you eat and any blood sugar highs or lows on that same log will be used to spot any patterns that might develop. Over time you’ll be able to spot trends and understand how your body is working a bit better.

Reactive Hypoglycaemia is manageable! Make sure you are following our dietary guidelines and instructions – eat protein first, then the complex carbohydrates and lastly the healthy fats.

You will need to experiment with foods and figure out what YOUR triggers are, and what foods work BEST to bring you back from a sugar crash.

Here is what happens in experiment A, when 12 patients 2 years after gastric bypass suspected on Reactive hypoglycaemia, are given a high carbohydrate meal of 8 oz. of orange juice, 1 slice of toast with 1 tsp. of margarine and 2 tsp. of jam (79% carbohydrate, 11% fat and 10% protein, 405 calories) and their glucose and insulin levels are measured every 30 minutes for 3 hours:

Glucose peak after carbs

Note the high peak of glucose (red) and insulin (purple) levels at 30 minutes and the drastic fall in glucose to below normal levels (<82 mg/dL) at 90 minutes.

Here is what happens when the same patients are given a low-carbohydrate meal was composed of decaffeinated black coffee or tea without sugar, 1 egg, a 1-oz. sausage patty, and a 1/2 oz. slice of cheese (2% carbohydrate, 74% fat and 24% protein, 415 calories).

glucose levels after balance diet

Note how the glucose level and the insulin level stay within normal levels and DO NOT SPIKE WIDELY as in experiment A.

(The scientific reference for this study is: T. A. Kellogg et al. / Surgery for Obesity and Related Diseases 4 (2008) 492– 499)

These experiments show us why we should not treat reactive hypoglycaemia like we do in diabetics. For example, diabetics are asked to eat candy to bring their blood sugar up quickly from an overdose of insulin (the cause of their hypoglycaemia).

That doesn’t work well in reactive hypoglycaemia post gastric bypass. It will just cause a new cycle of crashes and sugar spikes.

You need a BALANCE of nutrients, not sugar! For most patients peanut butter crackers – or – a handful of grapes and a slice of cheese or a granola bar works the best. The rule-of-thumb is a bit of simple carbohydrates to bring the crash up quickly, then a balance of protein and fat to keep the glucose up. When out of the house carry a granola bar for emergencies.

 

In cases of severe hypoglycemia with loss of consciousness, immediate treatment with 3-4 glucose tablets (5 g each) or 3-4 tsp of honey should be given to patients who can swallow. In no response call emergency services.

 
Some reportage and advice courtesy of www.weightlosssurgery.ca
 
 

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Comments

  1. Well I never ! Think this may be me, only the mild symptoms but there grim enough. Funnily enough I have changed from grabbing a biscuit to cheese and crackers. These stop the shaking and feeling faint much quicker. I was sure it was dumping and thinking I’d got something drastically wrong.
    Thanks Carol, I’ll keep an eye on it and hopefully deal with it much better.

  2. Glad it has helped Bonnie. I had a slight wobble recently and thought it was mild dumping and then realised it couldn’t be so I decided to explore further. I believe man post-ops confuse the two. It’s important to know the difference since they need to be treated differently. Stay well… C x

  3. Reading this, I’ve also realised there’s a difference, thought it was me, having different symptoms from what was described from the ‘dumping syndrome’- so thanks for that and will be printing out for Hubby to read and future reference. I also thought as I’m now 2yrs 6months since the op, I wouldn’t suffer, but I still do, at least I recogonise the signs.

  4. Glad it has helped Lin – so many times on forums I read people confusing the two – and it’s easy to do. C x

  5. Very interesting and helpful article Carol. I started to develop reactive hypoglycaemia around eight months post bypass. There was very little help around and our bariatric dieticians had no solutions to the problem. I experimented for over two years before I found the answer and was fascinated to read your article as it confirms what I found as being the answer. I have a diet which consists of good fats which seem to help, even though I don’t know why. During the day I can keep my hypos under control. My problem is In the night when I wake up sweating and heart pounding. I take a carb now before I go to bed, but it is very hit and miss. I can go weeks with no hypos then weeks where it wakes me every few hours. Have you any suggestions regarding night time hypos. Would love any pointers you could give me. Thanks Carol, I follow your recipes and find your articles so helpful. JUDY

  6. Hi Judy, many thanks for your kind comments! Nocturnal hypos, as you have discovered, are helped by having a bedtime snack. Having chatted to a professional the following is suggested. It is aimed more at people who suffer from diabetes but I think has some good useful information too:

    1. Check your blood sugar before bed. “For everybody with type 1 or type 2 diabetes, it’s absolutely critical that they check their blood sugar before going to bed to make sure they’re not going to have an episode of low blood sugar during the night,” says Helena W. Rodbard, MD, medical director of Endocrine and Metabolic Consultants, a private practice in Rockville, Md., and past president of the American College of Endocrinology.

    If your blood sugar levels are low at bedtime, eat a healthy snack before going to sleep. The size of the snack should be in proportion to the dip in blood sugar. For instance, a small drop in blood sugar requires only a small snack. If you use an insulin pump, consider reducing the active dose of insulin.

    2. Know the signs of low overnight blood sugar. Symptoms of hypoglycemia usually develop when blood sugar levels drop below 70 milligrams per deciliter (mg/dl). They include shakiness, sweating, confusion, erratic behavior, headache, and lightheadedness. With nighttime hypoglycemia, you may wake up with these symptoms or with a higher blood sugar reading that results from the body’s response to an overnight low. However, some people experience what’s referred to as “hypoglycemia unawareness,” which means that they don’t feel the symptoms of low blood sugar.

    Talk with your doctor about ways to recognize nighttime hypoglycemia, especially if you think you may have difficulty detecting it. “It’s a dangerous condition because people can’t tell when their blood sugar has dropped, since they may not have symptoms,” Dr. Rodbard says. “The body can get desensitized to it.” People with hypoglycemia unawareness are also less likely to wake up as a result of nighttime dips in their blood sugar.

    3. Don’t skip dinner. Skipping dinner or having only a light supper is one of the most common causes of nighttime dips in blood sugar, Rodbard says. Eat a healthy, well-balanced dinner every night and pay attention to portion sizes.

    4. Avoid excessive exercise late at night. Regular exercise is recommended, but strenuous exercise right before bedtime isn’t because it can cause blood glucose to drop overnight. This means you should avoid exercising within two hours of bedtime. If your blood sugar level is less than 100 mg/dl at bedtime after exercise, double your regular bedtime snack to prevent an unwanted dip while you sleep.

    5. Limit alcohol at night. Alcohol consumption can also increase the risk for nighttime hypoglycemia. In general, drink only in moderation — no more than one drink a day for women and two drinks a day for men — but don’t wait to indulge with a before-bed nightcap. If you do have a drink in the evening, enjoying it with food can minimize the chance of low blood sugar while you sleep.

    6. Be prepared. If you frequently wake up with symptoms of low blood sugar, have something available at your bedside, such as a soda or some juice, so you can react immediately without getting out of bed to treat it.

    I think the advice on a night-time snack; not eating too late or even too little; avoiding alcohol; not exercising excessively too late; and having something available by your bedside will all help.

    It’s a pity that we don’t get more informed help for this after WLS because often people mistake hypos for ‘dumping’ and there is a big difference between the two. The ways to deal with it are also very different. Hopefully these tips might help but if you find any others of your own (sounds like you’re very resourceful) then please do come back and pass on. C x

  7. I had surgery 14 months ago and recently started having hypos. There is no warning apart from lack of strength in my thighs and then within a minute I’m having a full blown hypo. Unfortunately, where I come from, there are no doctors that have any experience in gastric surgery (my local gvt send patients to the UK when our local hospital cannot perform a certain surgery) so I rely heavily on what I can find out online. My ‘gastric surgery’ doctor who is actually an endocrinologist tells me there is ABSOLUTELY NO CONNECTION between my surgery and my hypos even though I have research to back up my findings. Websites like this are a Godsend. Thank you.

  8. It took blacking out causing a car crash to realize what was happening to me. (glucose level 24). Now I am learning. I am 5 years post RNY, and about 2 years ago the “dumping” became more and more common. I did not experience it the first 2+ years. When I told my bariatric doctor (2 years post RNY) that “eating made me hungry” he just looked at me. I recently told my primary care doctor that the “dumping” was more common and even after non-sugary foods, almost every day, and was told to just watch what I eat. I never ever was told nor made the connection between “dumping” and hypoglycemia.
    I am under treatments now and working with a endocrinologist and dietician to figure this all out.
    Too many of us assume “just dumping” when could be something else and the medical providers often assume the wrong thing too. So your information should be shared to anyone who has had the RNY. Thank you.

  9. Wow!!! I knew it surely couldn’t be dumping syndrome as I’m careful after finding out what causes it!!! Thank you so much for this information I’ve been feeling so paranoid at what keeps happening to me ….for one minute be ok and the next minute craving salt and vinegar hula hoops sweating like crazy and feeling like I’m about to pass out I literally haven’t got the strength to walk when it happens and always need to sleep it off after a couple of packets of hula hoops and an ice lolly eaten with my eyes closed with a cold flannel on my head and window open ….what a state to get into Its so nice to understand what’s happening 👍 Thank you

  10. I had gastric bypass 8 years ago. Three years ago I started having hyper and hypoglycemia. I have tried to eat healthy, protein first diet but continue to struggle. I recently went to an endocrinologist and am now using a dexcom 5 to monitor my blood sugars. I am severe, I will have highs of over 300 and drop to under 20 in seconds. I live everyday in fear because my body is building a tolerance to the symptoms of my lows so I don’t feel it until it’s too late. I have passed out multiple times and had injured myself because of it. Still working on my diet but at this point am afraid to eat because I know the outcome. Any suggestions?

  11. I am so sorry you’re suffering in this way Jerri – I am no medic so I can’t offer any medical help nor have I come across anyone with symptoms and outcomes as serious as yours sound. I am posting this in case there is someone out there who is suffering in the same way who can share your concerns and their experience. Fingers crossed you can get some resolution and remedy to this debilitating situation. C x

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